Scholars International Journal of Obstetrics and Gynecology

Abbreviated Key Title: Sch Int J Obstet Gynec

ISSN 2616-8235 (Print) |ISSN 2617-3492 (Online)
Scholars Middle East Publishers, Dubai, United Arab Emirates
Journal homepage: https://saudijournals.com

Original Research Article

Evaluation of Retained Placenta: A Study in a District Hospital

Alam, S1*, Chowdhury, A. H2, Khan, S. A3, Saha, S4
1
Dr. Samiya Alam, Assistant Professor, Department of Gynecology and Obstetrics, Bangabandhu Sheikh Mujib Medical College,
Faridpur, Bangladesh
2
Dr. Afsana Haque Chowdhury, Registrar, Department of Gynecology and Obstetrics, Ibn Sina Medical College, Dhaka, Bangladesh
3
Dr. Sadia Afrin Khan, Assistant Director, BRB Hospitals Limited, Dhaka, Bangladesh
4
Dr Shilpi Saha, Associate Professor, Department of Gynecology and Obstetrics, Medical College for Women and Hospital, Dhaka,
Bangladesh

DOI: 10.36348/sijog.2022.v05i10.005 | Received: 19.08.2022 | Accepted: 26.09.2022 | Published: 15.10.2022

*Corresponding author: Alam, S
Assistant Professor, Department of Gynecology and Obstetrics, Bangabandhu Sheikh Mujib Medical College, Faridpur, Bangladesh

Abstract
Introduction: The placenta is an organ that is attached to the uterine wall and connects the fetus with the mother through
the umbilical cord. The placenta is said to be retained when it is not expelled out even half an hour after the birth of the
baby. The study aimed to evaluate the retention of the placenta. Methods: This was a cross-sectional study was
conducted at the Department of Obstetrics & Gynecology, Faridpur Medical College Hospital, Faridpur from June 2016
to November 2016. The sample was taken purposively and the sample size was 110. Patients were diagnosed with a case
of 'retained placenta' through proper history, and clinical examination. Written informed consent was taken from every
patient or their relatives. The information was collected in a preformed data collection sheet. Observation and results of
the study and statistical analysis were presented in tables. Data were analyzed by using the computer-based program
Statistical Package for Social Science (SPSS) software for windows. Result: Out of 110 study subjects about 58.18%
were found in the age group of 21-30 years and 20% were found in the age group of 20 years. The age of the patients
ranges from 18 to 40 years. Among 110 study subjects, 64.55% were from lower socioeconomic status, 27.27% were
from middle socioeconomic status and only 8.18% belonged to affluent socioeconomic status. The majority (74.54%) of
cases were delivered at home and 25.46% of cases were delivered at different levels of hospitals (among them 1.82% of
cases occurred in the institute where the study was done). Among them 20% were para- 1, 54.54% were para-2-4 and
25.46% of respondents were para ≥ 5. The majority (60%) of study subjects were admitted between 3 to 8 hours after
developing retained placenta, followed by 18.19% who came within 2 hours. Regarding the clinical presentation, 69.09%
of study subjects presented with anemia of varying degrees, 24.53% presented with shock, 5.45% presented with sepsis,
and only 0.93% (one patient) presented with acute renal failure. Concerning predisposing factors of retained placenta,
25.46% of study subjects were grand multipara, 11.82% had H/O MR or D & C, 10.90% with prolonged labor, 10.90%
respondents had IUD, 10% with past H/O retained placenta, 8.20% had preterm labor, 2.72% had H/O LUCS/ other
uterine surgery and 20% were without any predisposing factors. Among the respondents, 27.27% of study subjects
presented with genital tract trauma, 5.45% with sepsis, 5.45% with acute renal failure, 0.91% with DIC, 0.91% with
uterine prolapse 64.55% with no associated conditions/complications. Among the total study population, 58.18% of
retained placenta cases required manual removal under G/A, and 41.82% were managed by manual removal of the
placenta under deep sedation. Out of 110 respondents, 21.82% of cases of retained placenta did not require any blood
transfusion, 58.18% received 1-2 units and 20% received 3 or more units of blood transfusion. During management,
13.63% of study subjects developed uterine atony, 0.91% developed uterine inversion, 2.73% were complicated by
uterine perforation, 0.91% were complicated by anesthetic hazard; 81.82% had no complication during management. Out
of 110, 18.18% of study subjects experienced various complications. Among them 9.10% were managed by intrauterine
balloon tamponade,2.73% required hysterectomy, and 6.37% were managed by other measures. 70% of respondents
stayed in the hospital for 1-3 days, 26.36% for 4 to 7 days, and 3.64% stayed more than 7 days before discharge.
Regarding the outcome of retained placenta among study subjects, 80.91% improved and discharged, 10% had severe
anemia and required subsequent blood transfusion, 6.36% developed an infection, 0.91% developed acute renal failure
and 2 patients died (one due to DIC and another patient due to irreversible shock). Conclusion: The retained placenta is
an obstetric emergency. Rapid recognition and treatments are essential because heavy blood loss with coagulation

Citation: Alam, S, Chowdhury, A. H, Khan, S. A, Saha, S (2022). Evaluation of Retained Placenta: A Study in a District 455
Hospital. Sch Int J Obstet Gynec, 5(10): 455-461.
 Alam, S et al; Sch Int J Obstet Gynec, Oct. 2022; 5(10): 455-461
problems remains the lethal factor in this disease. Rapid control of hemorrhage should be the first initiative. Active
management of the third stage of labor lowers the danger by a significant percentage.
Keywords: Placenta, Shock, AMTSL, Labor, Anemia.
Copyright © 2022 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International
License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original
author and source are credited.
INTRODUCTION
The placenta is an organ that is attached to the
uterine wall and connects the fetus with the mother
through the umbilical cord. The expelled placenta is a
flattened, discoidal mass with a diameter of 15-20 cm
and a thickness of 2-4 cm at its center [1]. This organ
needs to provide its function such as transport and
secretion even during its development and thus all
developmental changes need to be under its function
[2]. The placenta is said to be retained when the
placental remnants are retained in the uterus even after
30 minutes following abortions and deliveries [3].
There are several causes of placental retention. The
simple adherent placenta is due to uterine atonicity in
cases of grand multipara, distension of the uterus,
prolonged labor, uterine malformations, or due to
bigger placental surface area. Sometimes placenta is
completely separated but retained due to poor voluntary
expulsive effort of the patient following exhaustive and
prolonged labor [4]. Another type is the constriction
ring placenta in which the placenta is completely or
partially separated but retained due to constriction or
contraction ring at the junction of the upper and lower
uterine segment. Again morbid adhesion placenta may
be partial or complete whereas partial adhesion is more
common than complete adhesion [5]. A morbidly
adherent placenta can be of three types. Placental
accreta: placental villi adherent to myometrium directly
due to a partial or complete absence of the decidua
basalis. Placenta increta: deep invasion of villi into the
myometrium. Placenta percreta: penetration through
the entire thickness of the uterine wall; Placenta accreta
may involve all of the cotyledons (total placenta
accreta), a few to several cotyledons (partial placenta
accreta) or a single cotyledon (focal placenta accreta)
[6]. The risks involved in prolonged retention of the
placenta include hemorrhage, shock due to blood loss or
due to frequent attempts of abdominal manipulation to
express the placenta, and puerperal sepsis [7]. Placental
retention can be prevented in many ways. During the
antenatal checkup, careful history taking can identify
the risk factors which may give rise to retained placenta
or change of morbid adhesion of placentae, such as the
previous history of placenta previa, dilatation, and
curettage, cesarean section, manual removal of placenta
or any surgery on uterus. Correction of anemia is very
important because it can cause uterine inertia due to
hypoxia of uterine muscles [8]. Moreover, antenatal
diagnosis in a suspected case of morbid adhesion of the
placenta nowadays is possible by using MRI or Color
Doppler [9]. The retained placenta develops in many
cases due to mismanagement of 3rd stage of labor [10].
Placental retention can be minimized in this stage by
© 2022 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates
Active management of the Third Stage of Labor
(AMTSL) which should be implemented in all cases of
labor. The placenta is usually delivered within 10-20
minutes but with active management, it takes 5-10
minutes [11]. Most cases of retained placenta present
with hemorrhage. Even it may present without
hemorrhage. So, the first initiative is to call for help,
then urgently mobilize all available personnel, and
rapid evaluation of the general condition of the women
including vital signs [12]. When the placenta is
completely separated but not expelled – inj. Oxytocin in
the drip should be started. If the placenta is undelivered
after 30 minutes of oxytocin stimulation and the uterus
is contracted attempt should be taken for delivering the
placenta by controlled cord traction [13]. 10 units of
oxytocin in 20ml normal saline to be administered
through the umbilical vein. Alternatively, it is shown
that the most effective technique is to inject 30ml of
normal saline with 10 units of oxytocin [14]. A
hysterectomy may be done if all measures fail [13]. The
study aimed to evaluate the retained placenta in the
uterus.
OBJECTIVE
General Objective
 To evaluate retained placenta cases with a
view to reduce the incidence of PPH
Specific Objectives
 To evaluate the clinical presentation of
retained placenta cases.
 To assess and analyze the predisposing factors
of retained placenta.
 To observe the maternal outcome of the
offered treatment to retained placenta cases.
METHODS
This cross-sectional study was conducted at
the Department of Obstetrics & Gynecology , Faridpur
Medical College Hospital, Faridpur from June 2016 to
November 2016. The sample was taken purposively and
the sample size was 110. Patients were diagnosed with
a case of 'retained placenta' through proper history, and
clinical examination. Written informed consent was
taken from every patient or their relatives. The
information was collected in a preformed data
collection sheet. Observation and results of the study
and statistical analysis were presented in tables. Data
were analyzed by using the computer-based program
Statistical Package for Social Science (SPSS) software
for windows.
456

Inclusion Criteria
 Patients who presented with retained placenta
following vaginal delivery
 Patients who developed retained placenta in
the In-patient Department who had undergone
vaginal delivery
 Patients who had a pregnancy duration of no
less than 28 weeks (both stillbirths and live
births, both singleton and multiple
pregnancies).
Exclusion Criteria
 Patients who had a pregnancy period of fewer
than 28 weeks.
 Patients who were unable to answer the criteria
question.
 Patients who did not give consent.
RESULTS
Out of 110 study subjects, about 58.18% were
found in the age group of 21-30 years and 20% were
found in the age group of 20 years. The age of the
patients ranged from 18 to 40 years (Table 1). Among
110 study subjects 64.55% were from lower
socioeconomic status, 27.27% were from middle
socioeconomic status and only 8.18% belonged to
affluent socioeconomic status (Table 2). Majority
(74.54%) of cases were delivered at home and 25.46%
of cases were delivered at different levels of hospitals
(among them 1.82% of cases occurred in the institute
where the study was done) (Table 3). Among them 20%
were para- 1, 54.54% were para-2-4 and 25.46%
respondents were para ≥ 5 (Table 4). Majority (60%) of
study subjects were admitted between 3 to 8 hours after
developing retained placenta, followed by 18.19% who
came within 2 hours (Table 5). Regarding the clinical
presentation, 69.09% of study subjects presented with
anemia of varying degrees, 24.53% presented with
shock, 5.45% presented with sepsis, and only 0.93%
Table 1: Distribution of respondents according to their age, (N=110)
Age in years
≤20
21-25
26-30
>35
Total
Table 2: Distribution of respondents according to their socioeconomic status, (N=110)
Monthly family income (BDT)
<5000 (low socioeconomic status)
5000-10000 (middle socioeconomic status)
>10000 (affluent status)
Total
© 2022 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates
Alam, S et al; Sch Int J Obstet Gynec, Oct. 2022; 5(10): 455-461
(one patient) presented with acute renal failure (Table
6). Concerning predisposing factors of retained
placenta, 25.46% of study subjects were grand
multipara, 11.82% had H/O MR or D & C, 10.90% with
prolonged labor, 10.90% respondents had IUD, 10%
with past H/O retained placenta, 8.20% had preterm
labor, 2.72% had H/O LUCS/ other uterine surgery and
20% were without any predisposing factors (Table 7).
Among the respondents, 27.27% of study subjects
presented with genital tract trauma, 5.45% with sepsis,
5.45% with acute renal failure, 0.91% with DIC, 0.91%
with uterine prolapse 64.55% with no associated
conditions/complications (Table 8). Among the total
study population, 58.18% of retained placenta cases
required manual removal under G/A, and 41.82% were
managed by manual removal of the placenta under deep
sedation (Table 9). Out of 110 respondents, 21.82% of
cases of retained placenta did not require any blood
transfusion, 58.18% received 1-2 units and 20%
received 3 or more units of blood transfusion (Table
10). During management 13.63% of study subjects
developed uterine atony, 0.91% developed uterine
inversion, 2.73% were complicated by uterine
perforation, 0.91% were complicated by anesthetic
hazard; 81.82% had no complication during
management (Table 11). Out of 110, 18.18% of study
subjects experienced various complications. Among
them 9.10% were managed by intrauterine balloon
tamponade, 2.73% required hysterectomy, and 6.37%
were managed by other measures (Table 12). 70% of
respondents stayed in the hospital for 1-3 days, 26.36%
for 4 to 7 days, and 3.64% stayed more than 7 days
before discharge (Table 13). Regarding the outcome of
retained placenta among study subjects, 80.91%
improved and discharged, 10% had severe anemia and
required subsequent blood transfusion, 6.36%
developed the infection, 0.91% developed acute renal
failure and 2 patients died (one due to DIC and another
patient due to irreversible shock) (Table 14).
N %
22 20
31 28.19
33 30
06 5.45
110 100
N %
71 64.55
30 27.27
09 8.18
110 100
457
 Alam, S et al; Sch Int J Obstet Gynec, Oct. 2022; 5(10): 455-461
Table 3: Distribution of study subjects according to the place of delivery, (N=110)
Place of delivery N %
Home 82 74.54
Thana health complex 10 9.09
MCH 07 6.37
Private clinic 06 5.45
District hospital 03 2.73
Faridpur Medical College Hospital 02 1.82
Total 110 100

Table 4: Distribution of respondents according to parity, (N=110)

Para N %
1 22 20
2-4 60 54.54
≥5 28 25.46
Total 110 100

Table 5: Time interval between the retained placenta and hospital admission, (N=110)
Time (in an hour) N %
0-2 20 18.19
3-8 66 60
9-24 18 16.36
>24 06 5.45
Total 110 100

Table 6: Distribution of study subjects according to the clinical presentation of retained placenta, (N=110)
Clinical presentation N %
Anemia 76 69.09
Shock 27 24.53
Sepsis 06 5.45
Acute renal failure 01 0.93
Total 110 100

Table 7: Distribution of patients according to predisposing factors of retained placenta, (N=110)

Predisposing factors N %
Grand multiparity 28 25.46
H/O MR or D&C 13 11.82
Prolonged labor 12 10.90
IUD 12 10.90
Past H/O retained placenta 11 10
Preterm labor 9 8.20
H/O LUCS/ other uterine surgery 3 2.72
Absence of any predisposing factors 22 20
Total 110 100

Table 8: Conditions/complications associated with retained placenta (N=110)

Complication/Associated condition N %
Genital tract trauma 30 27.27
Sepsis 6 5.45
Acute renal failure 1 5.45
DIC 1 0.91
Uterine prolapse 1 0.91
No complication 71 64.55
Total 110 100

© 2022 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 458
 Alam, S et al; Sch Int J Obstet Gynec, Oct. 2022; 5(10): 455-461
Table 9: Distribution of respondents by mode of management of retained placenta (N=110)
Mode of management N %
Manual removal under G/A 64 58.18
Manual removal under deep sedation 46 41.82
Total 110 100

Table 10: Distribution of study subjects according to the necessity of blood transfusion (N=110)
Blood transfusion N %
Not required 24 21.82
Required 86 78.18
1-2 unit 64 58.18
≥3 unit 22 20

Table 11: Distribution of respondents by a complication during the management of retained placenta (N=110)
Complication during management N %
Uterine atony 15 13.63
Uterine perforation 3 2.73
Uterine inversion 1 0.91
Anesthetic hazard 1 0.91
No complications 90 81.82
Total 110 100

Table 12: Distribution of respondents by management of complications of treatment of retained placenta (N=110)
Management of complications N %
Intrauterine balloon tamponade 10 9.10
Hysterectomy 3 2.73
Others 7 6.37
No management required 90 81.82
Total 110 100

Table 13: Distribution of subjects according to the length of hospital stay for retention of the placenta, (N=110)
Duration of hospital stay N %
24 hours to 3 days 77 70
4 days to 7 days 29 26.36
>7 days 4 3.64
Total 110 100

Table 14: Outcome of the study respondents (N=110)

Outcome N %
Complete recovery 89 80.91
Severe anemia 11 10
Infection 07 6.36
Renal failure 01 0.91
Maternal death 02 1.82
Total 110 100

DISCUSSION lack of money and awareness. So timely interference is

Regarding the age of the patients out of 110
study subjects, 28.18% were found in the age group of
21-25 years, 30% were of 26-30 years, 20% in the age
group of at or below 20 years, 16.37% at the age group
of 31-35 years. The age of the patient ranged from 18-
40 years which was found consistent with other studies
[15-17]. Regarding the socioeconomic condition of the
families it was seen that out of 110 cases 91.82% of
families had a monthly income below 10000 BDT. The
low-income group delays to decide between seeking
care and transferring the patient to the hospital due to a
deferred and the risk to the patients is increased.
Another study also showed the same scenario [17].
Regarding the place of delivery out of 110 study
subjects, 74.54% of delivery was conducted at home by
untrained Dai, 23.64% were done by the medical person
at a clinic or hospitals outside and 1.82% were
conducted by doctors at Faridpur Medical College
Hospital. The incidence of delivery at different levels
was quite similar to the other two studies [16, 18]. Two
other studies also showed that the incidence of home
deliveries was 92.87% and 68.75% [17, 12]. Findings

© 2022 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 459
 Alam, S et al; Sch Int J Obstet Gynec, Oct. 2022; 5(10): 455-461
showed that 74.54% of study subjects were para 1 to 4.
The percentage of grand multipara women (25.46%) in
this study is higher than that seen in the other two
studies [19, 17] but similar to that reported by another
author [20]. Regarding the interval between hospital
admission and development of the retained placenta, it
was found that most of the study subjects (60%) were
admitted between 3-8 hours after developing retained
placenta which is consistent with the findings of other
studies [16-18]. Concerning the clinical presentation
69.09% of study subjects presented with varying
degrees of anemia. Most of them were severely anemic,
24.53% presented with shock, 5.45% presented with
sepsis, and only 1 patient presented with acute renal
failure which was quite similar to a study [15]. A study
showed that 26 (36.61%) women had come in a state of
severe shock [17]. Moreover, the same picture was seen
in a study in another medical college hospital where
71.65% of patients were anemic, which was quite
understandable in the present study [21]. Regarding the
predisposing factors of retained placenta among the
respondents of this study, 25.46% were grand
multipara, 10.90% had H/O prolonged labor, 11.82%
were giving H/O MR/D&C, and 10% of respondents
with a history of retained placenta in the past, and
10.90% with IUD. The results were nearly consistent
with another study [15]. It was found in a study that the
previous history of retained placenta and prolonged
delivery in current pregnancy were significantly related
to retention of placenta. MR or Post delivery curettage
itself is not a cause of retained placenta, rather curettage
and infections after MR or puerperal endometritis can
be probable predisposing factors of retained placenta
[22]. A retrospective study showed that the recurrence
of retained placenta was 32% while there was placenta
accreta and a H/O multiple retained placentas [23].
Another study showed that 10% had a retained placenta
in the past which was consistent with the present study
[17]. A study by another author also showed that 16%
of patients had retained placenta before [24]. Regarding
the management of retained placenta, 58.18% of
patients were managed by manual removal under
general anesthesia and 41.82% by manual removal
under deep sedation. The use of umbilical vein injection
of oxytocin with normal saline was not used in the
management of patients despite some beneficial effects
documented in the Cochrane library because of no
experience with the technique [25]. The requirement for
transfusion was more among the patients managed by
manual removal under general anesthesia. In this study,
86 (78.18%) patients received blood transfusion which
greatly differs from the findings of the other two
studies, where the percentage was 40% and 10%
respectively [22, 24]. This may be because pregnant
women in this country suffer more from anemia. Need
for blood was more than the amount transfused but the
patient could not afford it due to a lack of money,
donors, and also blood in the blood bank. Regarding the
length of hospital stay by study subjects, it showed that
70% stayed in the hospital for 1-3 days, 26.36% for 4 to
© 2022 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates
7 days, and only 3.64% had to stay more than 7 days.
The result is consistent with the study done by other
two authors [15, 16]. Findings also showed that 80.91%
of the study subjects recovered more or less completely
(including mild to moderately anemic patients); 10%
suffered from severe anemia; 6.36% developed sepsis,
and 0.91% developed acute renal failure. Unfortunately,
2 patients died, one due to Disseminated Intravascular
Coagulation (DIC) and one due to irreversible shock.
The result was also relatable to another study [15].
Limitations of The Study
The study was conducted in a single hospital
with a small sample size. So, the results may not
represent the whole community.
CONCLUSION
The retained placenta is an obstetric
emergency. Rapid recognition and treatments are
essential because heavy blood loss with coagulation
problems remains the lethal factor in this disease.
Mismanagement of 3rd stage of labor is one of the major
causes of uterine inertia leading to postpartum
hemorrhage and retained placenta. Identification of the
risk factors for developing retained placenta during
antenatal care and properly conducted delivery with
active management of the third stage of labor can
reduce the frequency of retained placenta. All the
resources should be utilized for the proper training of
birth attendants so that the high-risk cases can be
identified at the right time and should be referred to a
well-equipped institution where blood transfusion and
operative facilities are available. The evaluation of
retained placenta cases is necessary, as PPH is the most
common cause of maternal mortality in our country.
The maternal outcome in retained placenta cases is
inversely proportional to the time required for
treatment.
RECOMMENDATION
For prevention and proper management of
retained placenta cases, all deliveries must be
conducted by skilled birth attendants preferably in an
institution. All pregnant mothers having predisposing
factors for retained placenta must deliver in a hospital
equipped with skilled manpower and facilities to deal
with obstetrical emergencies including surgery and
blood transfusion. A multi-center large-scale study may
be done for a better understanding of the incidence,
predisposing factors, and management options of
retained placenta Price of the retained placenta can be
extremely devastating if not managed early. Besides
other required measures, patient and patient party
motivation is also important, as the decisions are made
by the family members in our society.
Funding: No funding sources
Conflict of interest: None declared
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 Alam, S et al; Sch Int J Obstet Gynec, Oct. 2022; 5(10): 455-461
Ethical approval: The study was approved by the
Institutional Ethics Committee
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